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C O L L A B O R A T I V E C A S E M A N A G E M E N T

A Medical Director’s Perspective


Demonstrating the Value of a Physician Advisor Program
By Edward A. Ross, MD and Frank B. Bellamy, RN, MSN, CCRN, ACM

As case management practice continues to evolve and expand, encompassing a broad range of patient care issues and specific responsibilities,
many organizations have recognized the need for a physician advisor (PA) program which specifically supports case management. However,
for organizations that are implementing the PA role for the first time, demonstrating the value of integrating such a program – and justifying
the allocation of funds and resources necessary to do so – is critical in order to ensure its permanence and establish its credibility. This article
will examine an innovative PA program at Shands at the University of Florida (Shands UF), and provide insight into effectively demonstrating
the value and return on investment (ROI) of a PA program.

BACKGROUND patients not meeting those criteria. The PA could also facilitate
There were a number of considerations which factored into the communication with the attending physician to facilitate advance-
decision to implement a PA program at Shands UF, but chief among ment of care or if appropriate, discharge. Either action would reduce
them were two primary issues: appropriate status determination of or eliminate the hospital’s risk of denial of payment for such cases.
patients into inpatient or outpatient status, and length of stay (LOS)
reduction. Status determination had long been a challenge for the IDENTIFYING THE KEY STAKEHOLDERS
organization, and Shands UF’s case management team made an With any new program or initiative, there are a number of key
appeal to the organization’s senior leadership for a PA program which stakeholders or constituents, who each have a specific expectation
might assist in this capacity. In 2006, Shands UF’s case managers iden- of – or vested interest in – the program. Though any program
tified a substantial number of avoidable days related to physician designed for improvement is aimed at benefiting the organization,
practice patterns. It was determined that implementing the PA role the stakeholder group is comprised of more than just the facility,
would help reduce avoidable days and improve through-put by and includes a number of specialists and groups throughout the
opening bed availability, ultimately reducing the cost associated with continuum. In order to clearly demonstrate the value of an initiative
these days. such as a PA program, those individuals supporting the program
Assisting with patients not meeting criteria was also an expec- must remain aware of the measures and outcomes that are tied to
tation of the PA role. It was expected that a PA could aid in establish- these groups, departments, and organizations, and strive to clearly
ing medical necessity outside of the published criteria set for those demonstrate that their expectations have been met. Meeting and
exceeding expectations and program goals will
Shands at the University of Florida validate the PA role amongst constituents, and
Department of Patient and Family Resources ultimately strengthen the network of support
Case Management around the program.
Twelve Months Ending June 30, 2008 Perhaps the party with the greatest stake in the
Continued Stay Write-Offs PA program at most organizations is case manage-
ment, as they are typically the driving force behind
FY 2007 FY 2008 Savings
Amount 1,494,346.36 895,726.87 598,619.49 the program and are ultimately held accountable
Cases 152 136 16 for its outcomes. This was also true of Shands UF,
Days 1176 593 583 as the case management team identified the need
Amount - Clinical criteria/documentation 452,813.67 178,213.55 274,600.12 and proposed the concept of the program to the
Cases - Clinical criteria/documentation 68 52 16 organization’s senior leadership.
Days - Clinical criteria/documentation 280 119 161
Accordingly, the administration which
Obs - to - IP MCR Conversions authorizes the implementation of the PA program
Minimum per month 5 is also a key stakeholder. At Shands UF, the clinical
Average per case (diff of DRG v. OP pymt) 3,750.00 specialist overseeing case management proposed
Annualized 225,000.00
the concept to the organization’s Vice President of
Total Savings 499,600.12
Annual Salary Expense xx,xxx.xx Operations. The organization’s senior leaders were
Return on Investment 581% receptive to the idea, and approved the implemen-
tation of the program. However, the leadership at
FIGURE A: COST SAVINGS AND ROI EXECUTIVE SUMMARY Shands UF clearly outlined their expectations of

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Demonstrating the Value of a Physician Advisor Program (continued from page 14)

the new role, and explicitly stated that if a certain measure of ROI was facilities and returning to the acute care setting within days of their
not demonstrated following the program’s inception, the organization discharge. Such clinical outcomes are not beneficial to the patient,
would be unable to sustain the PA role. and as a result of this discovery, Shands UF’s further examined cor-
An institution’s medical staff might also be listed among its relations and trends in rehabilitation discharges and readmissions to
key stakeholders. At the time the PA program was implemented determine the cause of the issue and employ preventative measures.
at Shands UF, the organization’s interim dean of the college of
medicine was considered a key stakeholder within the medical
staff. The PA role not only achieved outcomes which benefited this
key constituent, but the PA also served as a liaison between the
college of medicine and the case management team, communi-
cating concerns and issues and demon-strating that positive Measuring key outcomes
outcomes were being achieved.
Though there are a number of individuals who rely on the PA,
there are none that stand to lose or gain as much as the patient.
and charting metrics
The overall goal of a PA program is ultimately to achieve improved
outcomes for the patient, and provide him or her with optimal is crucial to effectively
care. With this being said, the patient is the most important stake-
holder or constituent, and all efforts and interventions made demonstrating the ROI
through the PA program should be done with the patient’s best
interests in mind.
of a PA program.
DEMONSTRATING THE ROI
What to Measure
Measuring key outcomes and charting metrics is crucial to
effectively demonstrating the ROI of a PA program. Advocates of
a PA program should carefully consider what metrics and measures Presenting the Data
are the most powerful indicators of the success of the PA role. Such There are financial implications and a certain degree of fiscal
data should include standard measures that are recognizable across return which must be demonstrated in order to validate the program
institutions, including: to senior leadership. Though the benefits of an effective PA program
• LOS extend far beyond the monetary savings it produces, when combined
with improved patient outcomes, such data is powerful in justifying
• Adjusted LOS the investment required to launch the program. The PA’s reporting
• Reasons patient has not been discharged structure should highlight these financial returns, while remaining
• Delays in transfers to rehabilitation, skilled nursing facilities, brief and concise. Less is more when communicating the progress of
long-term care, or other facilities a PA program to leadership. Regular reports should include only the
most important and powerful measures for the organization in a
• Overturned denials
concise summary format. Reporting should be:
• Case mix index • Regular
• Observation rate • Systematic
• Medical necessity • Timely and proactive
Though the aforementioned measures are standard, through the Perhaps the most important of these key factors is timeliness.
review processes other data points may evolve that should be added Case management leadership should not wait for senior leadership to
to the list of standard measures. For example, the case management request reports. Providing the organization’s key decision makers
team and the utilization management committee at Shands UF with data and progress metrics proactively is a direct reflection of the
identified a trend in patients being discharged to rehabilitation program’s efficiency and serves to further establish credibility.

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Demonstrating the Value of a Physician Advisor Program (Figure B)

Referral
Referral Days Reimbursement Recovery Reimbursement Recovery
Response Referral Outcome
Reason Saved or DV Savings or Savings BASIS
Date

3 7/1/07 Rolled to IP 7,698.32 DRG reimbursement

1 7/8/07 Rolled to IP 8,377.55 DRG reimbursement

1 7/3/07 MD-to-MD; 4 days approved 4 10,705.80 Last 4 days charges

1 7/5/07 Rolled to IP 16,354.37 IP reimbursement

1 8/3/07 Rolled to IP 1 1,846.35 Medicaid per diem

6 8/2/07 Expedited DC on a Friday 2 790.00 Direct variable 1 day

1 7/9/07 Got 3 days approved 3 5,400.00 Medicaid per diem

1 8/8/07 S/W pt DC earlier 1 541.00 Direct variable 1 day

3 7/9/07 Rolled to IP 11,632.57 DRG reimbursement

1 7/9/07 Rolled to IP 8,736.08 DRG reimbursement

1 7/9/07 MD-to-MD; 1 day overturned 1,846.35 Medicaid per diem

3 7/10/07 DC expedited 1 541.00 Direct variable 1 day

1 7/12/07 MD-to-MD; 3 days denial overturned 3 5,539.05 Medicaid per diem

1 7/23/07 Rolled to IP 10,253.06 DRG reimbursement

1 8/7/07 Got SW order to expedite DC 1 566.00 Direct variable 1 day

8/8/07 1 566.00 Direct variable 1 day

1 8/9/07 Got IP order 8,736.08 DRG reimbursement

1 8/9/07 Rolled to IP 9,737.46 DRG Reimbursement

8/16/07 Expedited DC to rehabilitation 1 1,702.00 Direct variable 1 day

1 8/17/07 MD-to-MD; conversation overturned 2 day 2 3,696.76 Medicaid per diem

1 8/20/07 MD-to-MD; conversation overturned 1 day 1,846.35 Medicaid per diem

1 8/22/07 Rolled to IP 10,253.06 DRG reimbursement

3 8/23/07 Rolled to IP 9,164.41 DRG reimbursement

Total Reimbursement Recovery or DV Savings 136,529.62


FIGURE B: COST SAVINGS TRACKING DETAIL, JULY – AUGUST 2007

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Demonstrating the Value of a Physician Advisor Program (continued from page 15)

BEYOND DOLLARS AND CENTS at Shands UF – will leave the facility with an advanced understanding
The ultimate goal of a PA program should always be to produce and appreciation of case management practice. These physicians
the best possible outcomes for the patient. In the process, cost savings have been exposed to case management and utilization manage-
will often be achieved for the hospital as well, but the patient’s best ment protocols and procedure throughout their training in clinical
interests should always remain the program's principle motivator medicine, and will expect their charts to be reviewed from a financial
The Cultural Impact and health care delivery perspective. These physicians will carry this
At many organizations the most difficult ROI indicators to awareness and understanding to their next organization and through-
measure are those that are non-financial, however, such benefits out their careers in medicine.
are often the most beneficial for both the patient and the care
team. At Shands UF, one of the most valuable outcomes achieved CONCLUSION
as a result of the PA program’s implementation is a change in At Shands UF, the PA program continues to clearly demonstrate
culture. This change in culture includes physician awareness, its ROI, both fiscally and in terms of positive outcomes for the patient
education, and buy-in. Though difficult to quantify, such an and the care team. By fiscal year end, the program’s return on invest-
outcome is invaluable. ment was determined to be over 500% since inception (see Figure A,
For example, prior to the program’s implementation, there page 14). The program has also resulted in more expedient discharges,
were attending physicians who demonstrated a lack of under- as well as numerous saved days throughout the continuum (see
standing regarding reimbursement and what is considered Figure B, page 16).
medically necessary. Case management and utilization manage- Additional outcomes attributed to the PA program include:
ment’s attempts at educating such practitioners had not been • Reduced excess utilization
fruitful prior to the program’s implementation – not because their
message had not been appropriate or well-crafted, but rather • Reduced avoidable days
because it was not communicated by a peer. The reality is that • Reduced payment denials
some physicians are more receptive to such messages when they
are being conveyed by a fellow physician. The PA role has provided • Improved timeliness of reimbursement for the organization
this peer-to-peer communication, and as a result, the level of An effective physician advisor program fosters working relation-
awareness and education has dramatically increased amongst ships between case management and physicians, improves upon
physicians who previously demonstrated a lack of understanding. current processes, and produces quality outcomes for both the
The benefits of peer-to-peer communication extend beyond the patient and the care team. Not all of these outcomes are measure-
facility’s internal medical staff. Such credibility improves commu- able, however, by providing consistent, standard metrics for those
nication between the organization and medical directors for payor that are quantifiable and clearly communicating the more intangible
organizations as well. Messages that might have previously been outcomes, a PA program will be truly validated and its value will
ineffective when delivered by case management are often better become evident.
received when conveyed by the organization’s PA. This was evident
Edward A. Ross, MD, is an Associate Professor for the Division of
at Shands UF’s, as the organization’s PA has developed a close
Nephrology, Hypertension, and Transplantation, and has been a
working relationship with medical directors from payor organizations.
faculty member at the University of Florida since 1990. He earned
When a problematic case arises, the organization’s PA often calls the
his MD from Boston University in Boston, MA. He has been the
payor’s medical director on his or her cell phone and discusses the
Physician Advisor/Medical Director for Utilization Management
case in order to reach a resolution. Though mainly intangible, this
at Shands Hospital for three years. He is also Director of the End
benefit is invaluable to case management as it saves hours worth
Stage Renal Disease Program.
of phone calls, faxing medical records, and research.
There is also evidence of a cultural shift at Shands UF among the Frank B. Bellamy, RN, MSN, CCRN, ACM, has been the Clinical
facility’s resident physicians. As Shands UF’s PA program approaches Specialist/Utilization Management at Shands at the University
its three-year anniversary, the class of physicians who began their of Florida for four years. He holds his BSN and MSN degrees from
residency during the PA program’s implementation also prepares to the University of Florida in Gainesville, FL. During his 30-year
graduate. This class – as well as numerous other medical students, career he has held director-level positions in critical-care nursing
interns, and graduate physicians who have completed their training and case management.

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